Clinical trials play an important role in defining optimal antiretroviral regimens, but they do not adequately reflect the experience of antiretroviral use in HIV clinical practice. Trial participants may be healthier, more motivated than typical clinic patients, and more adherent to HIV medication regimens. Delivery of HIV care in clinical trials is also more regimented and algorithm-driven than clinical practice. These differences may explain why even experienced HIV clinics have not achieved the same health outcomes as reported in clinical trials. Improving the delivery of clinical care has been identified as a national priority by the Institute of Medicine, and computer informatics are an underutilized resource. Dr. Robbins will assess factors that influence HIV-related health outcomes among over 800 patients followed at the MGH HIV clinic, design and test informatics-based provider alerts and support systems, and then use these insights to develop and pilot test an informatics-based system designed to optimize delivery of HIV clinical care. The specific aims are: Aim #1: To determine and compare the effectiveness of email and electronic medical record alerts that notify patients' HIV providers of initial virologic failure or toxicity (anemia, neutropenia, thrombocytopenia, liver toxicity, and hyperlipidemia) and suboptimal clinic follow-up. Aim #2: To assess known and identify novel predictors of important HIV health outcomes (such as initial loss of virologic control, toxicity, and suboptimal clinic follow-up), to compare these predictors with those reported for clinical trials, and to assess their potential utility in an informatics-based clinical decision-support system. Aim #3: To design and test in a randomized controlled trial whether an informatics-based clinical decision-support system that combines published treatment guidelines with the findings of Aims 1 and 2 will improve HIV health outcomes, including decreased rates of virologic failure, toxicity, and suboptimal clinic follow-up, among patients followed at a large urban HIV clinic. This career development award will allow Dr. Robbins to acquire additional research skills and experience through coursework and mentoring by a diverse team of internationally recognized researchers in HIV and general medicine, allowing him to complete the transition into an independent HIV investigator.